Provider Demographics
NPI:1457352288
Name:MANIS, MARY (MS MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MANIS
Suffix:
Gender:F
Credentials:MS MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RUSK STATE HOSPITAL
Mailing Address - Street 2:1601 NORTH DICKINSON DRIVE
Mailing Address - City:RUSK
Mailing Address - State:TX
Mailing Address - Zip Code:75785
Mailing Address - Country:US
Mailing Address - Phone:903-683-7436
Mailing Address - Fax:903-683-7302
Practice Address - Street 1:RUSK STATE HOSPITAL
Practice Address - Street 2:1601 NORTH DICKINSON DRIVE
Practice Address - City:RUSK
Practice Address - State:TX
Practice Address - Zip Code:75785
Practice Address - Country:US
Practice Address - Phone:903-683-7436
Practice Address - Fax:903-683-7302
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1974207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1286064-06Medicaid
TX127101OtherSUPERIOR
TX0011KWOtherBLUECROSS BLUESHIELD
TX1286064-07OtherMEDICAID THSTEPS
P00166344OtherMEDICARE RAILROAD
F52630Medicare UPIN
TX1286064-06Medicaid